Studies estimate that 90% of people with a diagnosis of autism experience sensory abnormalities. The majority of those affected will not have a psychotic illness, however young people with autism are three to six times more likely to develop schizophrenia than their neurotypical equivalents.

This report considers the diagnostic complexities, potential risks and challenges of navigating concurrent referral and treatment pathways for an adolescent awaiting an autism assessment, who has psychotic-like experiences.

An adolescent female was referred to our Tier 3 service for an autism assessment. Whilst on the waiting list, our service was contacted on three occasions by adults who knew the patient, expressing concerns that she had psychotic-like experiences, namely perceptual abnormalities which had not been included in the original referral.

On the third occasion, approximately six months after the initial referral was accepted, a decision was made to review the patient face-to-face to explore these symptoms further.

During this review she appeared to have positive and negative symptoms of schizophrenia, including perceptual abnormalities in all sensory modalities, thought block, paranoid ideation and a mood incongruent affect. Her sleep cycle was reversed and she had not attended school for several years.

She was subsequently referred to the Early Intervention Psychosis Service, underwent an eight week assessment and was discharged back to the autism service.

Young people in the UK are on average waiting nine months for an autism assessment, although some are waiting up to seven years for treatment. NICE recommends that young people referred due to first episodes of psychosis are seen within two weeks, as delays in treatment can negatively impact on the patient's response to treatment.

Diagnostic uncertainty can arise due to overlapping symptoms, clinician inexperience and difficulties with eliciting a thorough history. With waiting times for autism assessments growing, young people who may have psychotic symptoms are waiting longer to see a clinician. The referral pathways for neurodevelopmental and psychiatric disorders typically exist independently, but inclusion on one pathway can create barriers in accessing the other.

It is good practice for comorbid psychiatric disorders to be considered by the referrer, when referring a young person for an autism assessment.

Clinicians should avoid making assumptions regarding the aetiology of symptoms based on the original reason for referral, explore symptoms thoroughly and refer to alternative services if needed.

Catatonia is a neuropsychiatric syndrome that affects motor, speech, and behavioural functions. The link between catatonia and cannabis use is complex and poorly understood, with limited evidence from case reports about the neuropsychiatric manifestations. This paper aims to describe an unusual presentation of catatonia precipitated by a drink made from cannabis leaves (a.k.a. ‘Bhang’).

Mr JP, a 22-year-old college student, was admitted to an acute medical ward in North India. The medical team sought psychiatry opinion following the unusual presentation: sudden onset of mutism, staring, and rigidity. Physical examination revealed tachycardia and redness of the eyes. Routine blood investigations, EEG and MRI-Brain were unremarkable. Urine drug screen was positive for cannabis. Initially reluctant due to fear of legal troubles, the accompanying friends later revealed a history of ingestion of cannabis leaves (Bhang) for recreational purposes twelve hours ago. Following the clinical diagnosis of catatonia, the lorazepam challenge test led to improvement in rigidity and verbal responsiveness. No overt psychotic symptoms, such as delusions or hallucinations, were noted at the time or during follow-up. JP had previously experimented with smoked cannabis without any diagnosed psychiatric or medical complications requiring inpatient management. He was abstinent from all forms of cannabis use over the past three months due to college exams and denied any illicit substance use. Over the next two days, as the effects of the ingested cannabis wore off and oral lorazepam (6 mg/day) was continued, JP was back to his previous self with stable vital signs. He was discharged from the hospital with a plan to taper and stop lorazepam on an outpatient basis.

‘Bhang' has been a culturally acceptable cannabis form in the Indian subcontinent for centuries, providing an interesting cultural aspect to the case. This case highlights an unusual clinical instance of cannabis use; Oral ingestion led to a drastic presentation requiring hospitalisation, while the smoked form did not result in any similar sequelae. The study's limitations include the inability to test for synthetic cannabinoids and the lack of objective catatonia scoring scale(s).

With the surging popularity of cannabis use in recent years, it is essential to be aware of its various forms and exercise a high degree of suspicion towards unusual presentations. Further research is needed to understand the link between cannabis use and catatonia at the neurotransmitter level, mediated by individual risk factors.

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening idiosyncratic reaction to medications, specifically dopamine receptor antagonists. We report a case of a patient who initially developed extrapyramidal side effects (EPSE) and subsequently developed NMS after being treated with flupentixol depot.

A 64-year-old woman with an underlying recurrent depressive disorder with psychotic symptoms presented to a psychiatric hospital in June 2023. She exhibited self-neglect, low mood, paranoid delusions, and non-concordance to oral psychiatric medications.

In the first week, she declined all oral medications and was subsequently started on flupentixol decanoate (Depixol) depot injection at 40 mg once every 2 weeks. While showing good improvements in her mental state, she began complaining of akathisia and dystonia since July 2023, consistent with extrapyramidal side effects secondary to flupentixol.

The symptoms improved by lowering flupentixol to 30 mg every 2 weeks and adding procyclidine 5 mg twice daily and propranolol 20 mg three times daily.

In early September 2023, she experienced severe restlessness, stiffness, muscle weakness and felt hot and clammy over 36 hours. Physical observations showed fever, tachycardia, and hypertension. Examination revealed diaphoresis, rigidity in both upper and lower limbs, lower limb weakness, and normal reflexes. Blood tests indicated acute kidney injury (AKI) stage 1, deranged liver function tests, and a creatinine kinase (CK) level of 9405.

She was promptly admitted to the medical hospital for NMS and received extensive intravenous fluid rehydration along with oral Dantrolene. She made a complete recovery, and Depixol was discontinued. Two weeks later, she was started on quetiapine and gradually titrated to 50 mg once daily.

EPSE and NMS are associated with dopamine receptor blockade and commonly occur during the initiation or dosage increment of neuroleptic medications.

NMS is rare but life-threatening, presenting with manifestations of muscle rigidity, pyrexia, altered mental status, sympathetic nervous system lability and elevated CK.

In our case, our patient, who recently started taking neuroleptic medication, experienced EPSE and later deteriorated acutely, raising a high suspicion of NMS. It is essential to consider other possible diagnoses, including serotonin syndrome, malignant hyperthermia, malignant catatonia and electrolyte disturbances.

The commonly used diagnostic criteria include Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and Levenson's criteria but diagnosis of NMS remains clinical.

The crucial step after identifying NMS is to immediately stop the neuroleptic agent, followed by supportive medical treatment.

Early recognition and prompt treatment of NMS in our patient led to a full recovery.

Background

This case study describes the use of fluoxetine for reduction of pre-menstrual dysphoric disorder (PMDD) and bulimia nervosa symptoms. The case report also describes an increase in binge purge symptoms in the pre-menstrual period, along with other mood and cognitive symptoms. This supports a hormonal basis to the exacerbation of eating disorders. Patient consent was obtained prior to the publication of this report.

Case report

A 41-year-old lady with significant binge purge behaviours and mood disturbance was referred to our eating disorder service. She met the diagnostic criteria for bulimia nervosa after a thorough assessment, along with a component of mood dysregulation. She was prescribed sertraline for depressive symptoms in primary care. The patient described a worsening of mood symptoms, along with cognitive difficulties before the start of her menstrual cycle. After a medical review, we agreed on tracking these symptoms along with the binge-purge frequency for a period of two cycles. This was done using a PMDD tracker. The tracker reflected a clear diagnosis of PMDD along with an exacerbation of bingeing and purging symptoms before the start of a menstrual cycle. Following this, sertraline was switched to fluoxetine, and titrated up to its maximum dose of 60 mg a day.

Discussion

Following the commencement of fluoxetine, purging frequency dramatically reduced and subsequently stopped. Although mood symptoms still persisted, the specific mood symptoms along with cognitive symptoms in the pre-menstrual period reduced.

There is some evidence for the use of fluoxetine use for binge purge symptoms in bulimia nervosa. Fluoxetine has also been used either continuously or in the luteal phase for PMDD. This case report reflects the possible correlation between binge-purge symptoms and PMDD symptoms, and the potential use of fluoxetine for dual symptom reduction. PMDD still remains to be a significantly under-diagnosed condition in women. This case report also signifies the importance of exploring PMDD symptoms in eating disorders.

Obsessive-Compulsive or Related Disorders (OCRDs) comprise a group of disorders characterized by repetitive thoughts and behaviours and are fairly less prevalent among children. The recommended treatment for OCRDs involves high doses of antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), along with non-pharmacological management. However, evidence suggests that the risk of inducing mania with antidepressants may be especially high in children and adolescents aged 14 years and younger.

Here, we present a case of a nine-year girl, studying in fifth standard, with normal birth and development history, with no past/family history of psychiatric illness, presented with psychiatric illness of one-year duration and was diagnosed with Trichotillomania, Obsessive-Compulsive Disorder, Skin picking and Onychophagia as per the 11th revision of International Classification of Diseases (ICD-11). After initiating tab. escitalopram 5 mg for 10 days, child developed a manic episode, which leads to a diagnostic dilemma as well as difficulties in her further management. In view of the bipolarity, escitalopram was stopped and the child was started on tab. aripiprazole 2.5 mg which was gradually up-titrated to 7.5 mg/day, following which the manic episode completely resolved and there was also improvement in OCD, hair pulling and skin picking behaviour. Later for the remaining symptoms few sessions of Habit reversal therapy were held. Currently the patient is maintaining well on aripiprazole 7.5 mg for the last six months.

The uniqueness of this case is demonstrated through current limited literature on comorbid OCRDs and antidepressant coincident manic episode, especially in children in whom diagnosing manic episode possess a great challenge owing to various differential diagnosis. While deciding pharmacological therapy in children with OCRDs or Mania the efficacy as well as their safety profile should be considered. Currently there are no medications approved by FDA for treatment of acute manic episode in patients below 10 years of age and use of SSRI which are considered first line for treatment of some OCRDs may exaggerate the manic episode. In literature, second generation antipsychotics such as aripiprazole is found to be useful for the management of both manic episode (as monotherapy) as well as OCD (as an adjuvant). In this case aripiprazole monotherapy led to significant improvement in both groups of symptoms.

Thus, SSRIs should be used cautiously in children with OCRDs and aripiprazole along with other approved non-pharmacological management strategies can be considered as a good treatment option in children with OCRDs and anti-depressant coincident manic episode.

FND can be considered as an umbrella term that includes range of motor and sensory system dysfunctions with genuine symptoms including paralysis, tremors, sensory disturbance, speech disturbance and seizure. Functional seizures usually termed as Non-Epileptic attack disorder (NEAD) can result in profound persisting disability. Brief bouts of unprovoked and uncontrollable laughter, spontaneous in origin, combined with facial contraction in the form of smile, is termed as ‘gelastic seizures’. Modafinil is a dopamine modulating molecule for which evidence is accumulating towards its cognitive enhancement role in multiple domains. Furthermore, it has been shown to promote hippocampal neurogenesis and synaptic plasticity in pre-clinical studies. We report a case of FND in which pharmacological (Modafinil) and non-pharmacological interventions (Brain retraining) resulted in resolution of symptoms of probable gelastic episodes.

A 50-year-old lady who was referred by consultant neurologist to our Neuropsychiatry pilot service with episodes of uncontrollable laughing, singing, screaming and suffering from staggering and imbalance. Following these episodes, patient described sleeping for hours to days with fatigue. Her husband first noticed low mood 12 years ago during post-natal period. Treatment with fluoxetine reportedly contributed to ‘cyclical highs and mood variations’. One year later, her ‘gelastic episodes’ started and continued to occur every 2 or 3 months and they were brought on by a range of factors including tiredness, menstrual periods and stress. Patient also reported atypical cognitive deficits such as ‘losing vocabulary’ and ‘stuck every couple of seconds’. Furthermore, detailed history confirmed possible traits of attention deficit and hyperactive thinking since her childhood.

Following a comprehensive assessment, the role of the brain in the manifestation of her symptoms was discussed and agreed upon. Strategies based on Cognitive Behaviour Therapy principles such as active distraction, brain retraining, engaging in therapeutic activities and expressive writing were discussed and agreed upon. Following detailed risk-benefit analysis, modafinil was initiated at 200 mg dose in the morning. Patient made a remarkable recovery nearly back to her baseline with resolution of her gelastic episodes and thus improvement in her mental state. She continues to be stable in the community.

This case highlights the importance of recognising and treating cluster of symptoms which might belong to the impulsive-compulsive spectrum. This further emphasises the role of dopamine-modulating agents such as modafinil along with brain-retraining strategies.

Optimal management of Behavioural and Psychological symptoms of Dementia (BPSD) remains challenging. This report describes using nabilone, a synthetic cannabinoid, in a 61-year-old woman with Alzheimer's dementia (AD) experiencing progressive BPSDs.

AM was diagnosed with AD in February 2019 and prescribed donepezil and mirtazapine. In August 2021, her behaviour deteriorated, becoming paranoid, repeatedly pacing and developing expressive aphasia. Behaviours further declined leading to an admission to our dementia ward under the Mental Health Act 2007 in January 2022. AM showed limited response to medications including risperidone and mirtazapine which were switched to olanzapine and citalopram. “Controlled falls” were observed, during which AM placed herself suddenly onto the floor. In February 2022, she was witnessed having a self-terminating generalised tonic clonic seizure (GTCS) lasting 3 minutes and later witnessed having three more seizures. Computed tomography excluded acute intracranial pathology. She had no previous history of seizures. An electroencephalogram displayed focal slowing over the frontal region greater on the right and presence of sharp, transient, sharpened slow wave, triphasic waves and reported that epileptiform discharges can be seen in AD in the absence of epilepsy.

Behavioural charts, Cohen Mansfield Agitation Inventory (CMAI) and Neuropsychiatric inventory (NPI) questionnaires were used to monitor response. Decision was made to trial Nabilone in April 2022 due to minimal improvement. Nabilone was started at 0.25 mg daily and up-titrated by 0.25 mg fortnightly based on the response. Over the subsequent month there was a measurable improvement. This was temporarily halted due to issues with nabilone supply, together with cessation of lorazepam, showing worsening in behaviours. Nabilone was eventually restarted and increased to 1 mg once daily with promising effect.

There was a notable qualitative improvement in AM's engagement and communication with family and staff. Prior to treatment the frequency of aggressive incidents ranged from 25–35, reducing to five to ten incidents per day. Controlled falls largely ceased. The NPI Caregiver distress score dropped from 21 to 8 over three months; Frequency and severity scores dropped from 73 to 40 during the same period. CMAI scores dropped from 86 to 64 over two months.

We describe a measurable improvement in BPSDs and quality of life in a patient with severe AD. Reduction in irritability, agitation and improvements in sleep were observed after initiating nabilone. The mechanism of nabilone via CB1 agonism has shown to be neuroprotective and anti-inflammatory. This indicates a promising treatment for BPSDs.

20 year old patient open to mental health services since the age of 8. Through the years, they have had work-up and diagnoses of ADHD, ASD, Schizoaffective Disorder (with prominent erotomanic delusions) and sexual identity concerns.

They spent a number of years in psychiatric in-patient units following an index offence. Initially in an adolescent LSU and subsequently in an adolescent MSU.

After 5 years of their stay at the MSU, their transition to an adult rehabilitation ward was planned and completed.

20 year old, oldest of 5 siblings, born with no complications during or after pregnancy and at full-term. First referred to mental health services aged 6 regarding difficulties at school leading to a diagnosis of ADHD.

At age 13, re-engaged with mental health services following concerns around self-harm, disappearing from home, alcohol use. Also with difficulties around gender identity and sexual orientation. Shortly after, elements of ASD were identified, including social and communication difficulties and special interests which included single females.

Around age 16, patient developed erotomanic delusions. First towards a female friend in dance class – patient wanted to run away with them and have their babies, and carried a knife to hurt anyone who tried to get in their way, eventually leading to the index offence. In addition, there were similar erotomanic delusions with regards to at least 2 famous female music personalities.

With a significant mood component accompanying the psychosis, she was diagnosed and managed as having Schizoaffective Disorder.

The patient presented with a complex, multimodal presentation which took time and a comprehensive holistic approach. They were trialled on 3 different antipsychotics and eventually clozapine which needed stopping due to side effects. Best response was eventually observed with a return to olanzapine.

Patient also had 19 treatments of ECT (13 being high dose) with marked transient improvement.

Psychology, OT and the MDT largely focussed on building therapeutic relationships with the patient which gradually helped the patient develop insight around their erotomanic delusions and the impact on their life.

Despite the complexities of this case, it highlighted that a robust, consistent, holistic approach can change lives even though this may take some time. The patient was utilizing leaves off the ward, taking part in the education sessions and activities on the ward and has recently been transferred to an adult rehabilitation ward after years in an adolescent specialist in-patient service.

Clozapine, known for its efficacy in treating treatment-resistant schizophrenia, offers significant benefits. However, its use also carries potential cardiovascular side effects, such as myocarditis early in treatment and cardiomyopathy with prolonged use. This case highlights the challenge of balancing the risks of treatment-resistant schizophrenia relapse against the potential cardiovascular complications associated with clozapine therapy.

An adult male with treatment-resistant schizophrenia was initially prescribed clozapine but switched to paliperidone depot due to compliance issues. However, he relapsed shortly after and had to be restarted on clozapine, albeit at a lower dose due to associated tachycardia, supplemented with risperidone. After two years on clozapine, he was diagnosed with cardiomyopathy, prompting a cardiology review. Clozapine was withheld, and risperidone dosage was increased, but he experienced a severe relapse. Despite the risks, multiple multidisciplinary meetings and approval from the medication optimization committee led to his re-commencement on clozapine due to the treatment-resistant nature of his illness and associated risks.

Clozapine, a benzisoxazole derivative, is used for treatment-resistant schizophrenia and aggressive behaviours. Its pharmacological action involves D2 and 5HT2A receptor antagonism, affecting serotonergic, dopaminergic, adrenergic, cholinergic, and histaminergic receptors. However, severe side effects like agranulocytosis, seizures, myocarditis, tachycardia, and cardiomyopathy can occur. Cardiomyopathy incidence is rare (0.02–0.1%) with a mortality rate of 17.9%. Proposed mechanisms include undetected myocarditis and persistent tachycardia-induced changes leading to ventricular dysfunction. Common findings in investigations include raised CRP, leucocytosis, eosinophilia, increased lactate, elevated troponin, non-specific ECG changes, and ventricular dysfunction on echocardiography.

Clozapine poses rare but potentially fatal cardiac risks, including myocarditis and cardiomyopathy. Essential baseline investigations and close monitoring during the initial weeks are crucial. Persistent tachycardia may signal trouble. If suspected, serial monitoring of FBC, troponin, and CRP levels is recommended, with prompt management if confirmed with discontinuation of clozapine, as the cardiomyopathy is often reversible. A multidisciplinary approach involving cardiology is vital for optimal management. This is particularly crucial when weighing the risks of relapse in schizophrenia against the potential cardiovascular complications of clozapine therapy.

• • This case study investigates a rare occurrence of symptom transition in a chronic schizophrenia patient following high-frequency repetitive transcranial magnetic stimulation (rTMS), aiming to understand the unexpected shift from predominantly negative to positive symptoms.

• • rTMS, known for inducing changes in neuronal activity based on Faraday's law, is believed to enhance cortical excitability through high-frequency stimulation.

• • Schizophrenia, a severe and chronic mental disorder, presents with both positive (e.g., delusions, hallucinations) and negative symptoms (e.g., apathy). Current treatments, predominantly antipsychotic drugs, often show limited efficacy, especially for negative symptoms. Non-invasive neuromodulation techniques like rTMS are emerging as potential interventions.

This case involves a 27-year-old banking executive with a 30 months illness duration primarily marked by negative symptoms over the past 3 months. Despite various antipsychotics, there was no improvement, leading to the initiation of high-frequency rTMS on the left dorsolateral prefrontal cortex (DLPFC) as an adjunct strategy for persistent negative symptoms. Surprisingly, after the 5th rTMS session, positive symptoms like delusions and hallucinations emerged. Serial assessments demonstrated a decrease in negative symptom domain scores on PANSS but an increase in positive symptom domain scores on PANSS.

• • Results suggest that 5 Hz rTMS over the left DLPFC may have contributed to the transition to positive symptoms. The discussion explores limited literature on rTMS-induced positive symptoms, with case reports dating back to 2004 indicating the possibility of such induction. Studies propose a link between higher pulse frequency, motor threshold intensity, left prefrontal cortex stimulation, and longer trial durations with the exacerbation of positive symptoms, possibly linked to dopamine changes in specific brain tracts.

• • Recent trials indicate potential improvement in positive symptoms, such as excitement, with low frequency rTMS of the temporo parietal area. However, the efficacy of rTMS varies with the stimulation site, with left prefrontal rTMS showing promise for negative symptoms and left temporo-parietal junction stimulation possibly reducing auditory hallucinations.

This case report suggests that a subset of schizophrenia patients may experience a transient exacerbation of positive symptoms following rTMS. This underscores the need for increased awareness of potential side effects, serving as an exploratory study that calls for future research to refine these findings for a clearer understanding of rTMS-induced symptom switches in schizophrenia.

Clozapine is the most effective antipsychotic medication for patients with treatment-resistant psychotic disorders. Its discontinuation can precipitate relapse that can be often challenging to treat.

This is a case study of a female patient in her early 40s who is known to the mental health services with a diagnosis of schizoaffective disorder. She was admitted to acute psychiatric inpatient unit due to relapse characterised by psychotic, catatonic features and poor physical health condition due to refusal to eat and drink. She was stable on clozapine for more than a decade and had become unwell after discontinuation of clozapine in the community due to platelet count below 50 × 109/L with normal other parameters. Low platelet count was detected during routine monthly blood monitoring after a few years of commencing clozapine.

Whilst an inpatient, there were several trials of re-titration of clozapine which had to be withheld because of ambiguity regarding the cause of persistent thrombocytopenia. Other treatment options including alternative antipsychotics and 12 sessions of ECT were tried without any success. Haematologist opinion was sought at early stage of admission and blood investigations were done but there was delay in bone marrow biopsy due to practical issues.

The treating team re-commenced oral clozapine to which she remained initially non-compliant due to catatonic features. With advice from the specialist psychosis services a few doses of intramuscular clozapine was used to facilitate re-titration. Following regular compliance and optimisation of oral clozapine, there was significant remission of clinical symptoms, with patient returning to her baseline mental state and functioning. During the period of admission, platelet counts were closely monitored which kept fluctuating reaching sometimes below 30 × 109/L without any clear association with clozapine dose. No bleeding symptoms or signs were ever reported.

Clozapine is a medication with haematological side effects; however, low platelet count is very rare. This patient ultimately underwent bone marrow biopsy which established Immune thrombocytopenia. She was discharged to the community with a plan of continuing clozapine, close monitoring of blood count and regular follow-up with haematology services for further clinical management.

Careful clinical evaluation and timely investigation is important to establish the cause for side effects before associating it with clozapine and discontinuing the treatment. This helps in ensuring continuity of clozapine in patients who clearly benefit from long-term use of clozapine.

Very early onset schizophrenia is considered a rare and severe form of schizophrenia, with onset before age 13. Early initiation of antipsychotics significantly improves outcomes and prognosis. Treatment refractory status is not uncommon and clozapine currently remains the most effective option in this scenario. However, approximately 40–70% of antipsychotic-resistant patients do not respond, or respond only partially to clozapine. Additionally, many patients stop clozapine due to side effects, many of which are due to its active metabolite, nor-clozapine. Since clozapine-resistant patients have limited alternative treatment options, augmentation strategies must be considered.

This case study highlights one such augmentation strategy using fluvoxamine. Fluvoxamine inhibits CYP450 1A2 isoenzymes reducing the risk of the metabolite induced side effects and synchronously increasing plasma concentrations of clozapine.

The case study is of a 13-year-old female diagnosed with paranoid schizophrenia characterized by second and third person auditory hallucinations, delusions of persecution, paranoid pseudo-community, impulsive aggression and cognitive decline. She screened negative for developmental disorders, metabolic and genetic anomalies and medical co-morbidities. She had failed trials of two atypical antipsychotics. Clozapine was subsequently initiated and optimized to 500 mg/day (Serum Clozapine of 981 mcg/L). Partial improvement in symptomatology was observed. However, dose adjustments were difficult throughout due to side effects of clozapine and pharmacological agents such as Metformin, Lamotrigine, Ipratropium Bromide and Propranolol were used prophylactically to mitigate the side-effects. The polypharmacy, social isolation, excessive sedation and emerging obsessive-compulsive symptoms contributed to secondary negative symptoms. Low-dose fluvoxamine was subsequently used as an augmentation strategy following which improvement was noted.

Several studies have shown that co-administration of fluvoxamine may increase the steady-state serum concentrations of clozapine by a factor of 5. Optimizing the serum ratio of Nor-clozapine and clozapine levels, thereby, reduces the need for aggressive polypharmacy. Low doses of fluvoxamine inhibit the CYT activity, enough to raise the level of clozapine even when the dose of clozapine is reduced by 50% which is the target going forward for this patient.

Although current practice guidelines recommend clozapine mono-therapy for treatment resistant schizophrenia, augmentation of clozapine with fluvoxamine can be considered for those who do not respond adequately to clozapine mono-therapy or cease treatment due to its side effects. However, considering the unpredictable effect on clozapine plasma levels, concomitant use should ideally be initiated in facilities like a pediatric intensive unit where close surveillance is possible especially for side effects such as myocarditis especially in adolescents.

There is a bidirectional link between Depression and type 2 Diabetes mellitus (T2DM). Treatment of depression with selective serotonin reuptake inhibitors (SSRIs) may improve glycaemic control and may be beneficial for patients with comorbid depression and diabetes mellitus. The aim of the present study was to assess the effect of escitalopram on C-reactive protein (CRP) and glycaemic control in patients with comorbid T2DM and depression.

A prospective interventional follow up study was conducted in a tertiary health care institute in urban India. Adult males and females who were diagnosed with Type 2 DM, having depression as per ICD-10 and treatment naïve for both the disorders were included for the study. Participants with other psychiatric disorders, on thyroid medication or on any medication that can have effect on CRP levels, having history of any infection/allergic or inflammatory conditions were excluded from the study. Sociodemographic details were collected. The severity of depression was assessed using Hamilton Depression Rating Scale (HDRS) at baseline. Escitalopram was started and titrated upto required doses for each patient. Levels of fasting blood glucose, post prandial blood glucose, HbA1c (Glycated Hemoglobin) and CRP were also measured at baseline. At the end of 3 months, severity of depression scores and blood levels of above mentioned parameters were measured and compared with their baseline values.

A total of 125 patients (females-n = 70, males-n = 55) were included for the study. The mean age of the sample was 63.2 years (SD 10.6). Most of the participants were educated and employed. The mean HRDS score of the participants at baseline and at three months was 20.3 (SD 3.7) and 18.0 (SD 3.9) respectively. The mean HbA1C of the participants at baseline and at three months was 8.4 (SD 1.2) and 7.8 (SD 1.2) respectively. The mean CRP of the participants at baseline and at three months was 4.0 (SD 5.6) and 2.8 (SD 4.3) respectively. There was significant reduction in depressive symptoms (Z score= -6.894, P value <0.05), levels of HbA1C (Z score= -7.936, P value <0.05) and CRP levels (Z score= -6.158, P value <0.05) at follow up after treatment with escitalopram. No significant correlation was observed in these parameters across gender.

Treatment with escitalopram reduces the severity of depression and the ongoing inflammatory process amongst these patients.

Lithium is licensed to treat bipolar disorder, which is characterized by recurrent episodes of depression and mania/hypomania. It is also used as an adjunctive medication in patients who have inadequately responded to first and second line treatments of unipolar depression. Lithium has a narrow therapeutic index and the potential for toxicity requires levels to be closely monitored, particularly during any intercurrent illness or initiation of new medications. There is a rare but important effect of lithium toxicity of which there is little awareness: the Syndrome of Irreversible Lithium Effectuated Neurotoxicity.

A 57-year-old lady presented to the emergency department with a ten-day history of vomiting, diarrhoea, and abdominal pain. She had a history of recurrent depressive disorder managed with fluoxetine and lithium for ten years. On presentation, she was hypovolemic and required resuscitation with I.V. fluids. Clinical examination revealed significant ataxia and myoclonus. Neurological examination was limited by her inability to follow commands. She was orientated to person but not time or place. A collateral history was obtained from her husband. He reported a 3-day history of increasing confusion on a background of a 6-week history of gradual functional decline. History and examination were concerning for lithium neurotoxicity. Lithium level = 2.6mmol/L (0.4–0.8mmol/L), indicating lithium toxicity. Deterioration in renal function from baseline - urea 14.2, creatine level 120 umol/L eGFR 43mil/min. There was no evidence of infection, full blood count and CRP were within normal parameters. MRI brain showed mild degree global volume loss consistent with chronic small vessel microvascular ischaemia. She was commenced on haemodialysis in order to rapidly reduce her serum lithium levels.

Lithium levels post haemodialysis were 1.2mmol/L and within days fell to <0.4mmol/L. Further lithium treatment was held during admission, but she continued to exhibit signs of neurotoxicity. Two weeks post-admission her confusion persisted (MOCA 13/30). She remained tremulous and ataxic. A diagnosis of Syndrome of Irreversible lithium-effectuated neurotoxicity (SILENT) was made. She required intensive physiotherapy and occupational therapy input. 8 weeks post admission she had returned to her cognitive baseline and was mobilising independently.

SILENT syndrome is a rare consequence of lithium toxicity secondary to elevated lithium levels in the central nervous system which if sustained it is thought can lead to cerebellar demyelination as was evidenced in this case by our patient's symptoms. The insidious onset of her lithium toxicity in the community led to a prolonged period of toxicity that went undetected. No clear precipitating factor was identified. Vigilance is required for toxicity and this case highlights the importance of family members being aware of the signs. A patient when confused may no longer be able to advocate clearly for themselves or seek appropriate medical attention. The patient also delayed consulting with her GP as her GP practice was located an hour and a half from her home and she could not secure an appointment during the summer months. Patients prescribed lithium require timely access to GPs for monitoring and consultations. Despite her experience with toxicity, the patient opted to restart lithium due to a recurrence of depressive symptoms. She is adhering to close monitoring of serum lithium levels. The patient and her family received thorough psycho-education regarding symptoms and signs of lithium toxicity.

Background: Fahr's disease is a rare and complex neuropsychiatric disorder resulting from abnormal calcium deposition in the basal ganglia and cerebral cortex. It can have a profound impact on an individual's social functioning as well as causing a wide variety of neurological symptoms, cognitive deficits and motor impairment. A number of specific mutations have recently been identified in phosphate transporter and other genes, but around half of all cases have unidentified mutations. Impulsivity, aggression and violence may pre-date the other manifestations of the illness.

Case Report: Patient X is a 58 year old man currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. His first admission to hospital was at the age of 18 when he was diagnosed with mania. He had multiple further hospital admissions as well criminal convictions for acquisitive and violent offences. In 2005 he threatened to stab a stranger if he did not give him a cigarette and he was arrested and admitted to a medium secure unit under Section 37 with diagnoses of bipolar affective disorder and emotionally unstable personality disorder. He remained in secure hospital care until 2018 when concerns about Parkinsonian symptoms led to him being referred to a neurologist and a diagnosis of Fahr's disease being made on the basis of his CT findings. He was transferred to a locked rehabilitation service in 2019 but continued to exhibit challenging behaviour on a daily basis. After a reduction in the frequency and severity of his behaviour he was discharged to a care home, but this broke down after a few months as his assaultive and sexually inappropriate behaviour re-emerged.

Discussion: Fahr's disease is traditionally thought of as a late life neurological condition, but as with Huntington's disease neuropsychiatric symptoms of irritability, sexually disinhibited behaviour, impulsivity and aggression can occur early and may pre-date any neurological manifestations. Treatment is often difficult because of sensitivity to antipsychotic medication.

It is important to consider neuropsychiatric conditions in the assessment of adults presenting with antisocial behaviours, especially when these are associated with a change in overall functioning and an absence of adolescent conduct disorder. There is as yet no specific treatment for Fahr's disease, but early identification allows appropriate risk management strategies to be adopted.

Background: Late-onset Tay-Sachs disease (LOTS) is an autosomal recessive lysosomal storage disease due to a variety of mutations in the hexosaminidase-A gene which leads to accumulation of GM2 ganglioside in the brain. It typically presents in late adolescence with a slowly progressive spectrum of neurologic symptoms including lower-extremity weakness with muscle atrophy, dysarthria, incoordination, tremor and mild spasticity and/or dystonia. Psychiatric symptoms including mood disorder, psychosis and neurocognitive symptoms occur in around 50% of cases but are rarely the presenting feature.

Case Report: Patient X is a 35 year old man of Irish descent currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. He first presented to mental health services at the age of 17 with psychomotor agitation, rapidly changeable moods, manic-like symptoms and sexual disinhibition. He was diagnosed with schizoaffective disorder, attention deficit hyperactivity disorder and Asperger's syndrome and he had several compulsory hospital admissions over the next five years before a prolonged period of rehabilitation and discharge to a residential home for people with autistic spectrum disorders. However, he continued to exhibit disruptive behaviour, often triggered by periods of insomnia and had further hospital admissions. When he was 31 his brother was diagnosed with LOTS and this led to him being tested and found to have the same mutation.

Discussion: There had been no suspicion of a neuropsychiatric disorder prior to the diagnosis of the patient's brother with LOTS and he was treated with conventional psychotropic medication with limited success. However, when the case records were obtained from his first hospital admission there was evidence of dysarthria although the significance of this was not appreciated. With hindsight many of his other symptoms can be seen as indicative of a neuropsychiatric disorder.

It is important to take a family history and consider a neuropsychiatric condition in families with multiple affected individuals. There are as yet no specific treatments for LOTS, and management is aimed at symptom reduction and enhancing quality of life, but a number of disease modifying strategies are being investigated including enzyme replacement therapy, pharmaceutical chaperone therapy, substrate reduction therapy, gene therapy, and hematopoietic stem cell replacement therapy, making it even more important the condition is recognized early.

To understand the prescribing habits and trends of clinicians in a large ADHD clinic and the medication journey of patients from point of diagnosis to the point of agreeing a shared care plan with primary care services.

This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. Following approval by the Clinical Governance body of the practice, in June 2023, all patients with a SCP between the years 2019 and 2021 were identified. Data collected included patient demographics, date that medication was started, discontinued, or switched along with associated reasons. Additionally, to better understand the time taken to gain publication of a SCP, the amount of clinician-patient facing time was recorded, including the number of brief follow-up appointments, number of repeat prescriptions and number of clinician to patient emails. Patient data was fully anonymised and any identifiable data removed.

All but one patient was started on a stimulant medication immediately following diagnosis, in line with national prescribing guidance. Atomoxetine was the medication of choice for a patient with a previous history of stimulant intolerance. 74% (n = 95) of patients were started on lisdexamfetamine, 20% (n = 25) were started on methylphenidate long-acting formulations and five patients on short-acting methylphenidate agent.

Of the 95 patients initiated on lisdexamfetamine, 78 (82.1%) were continued on lisdexamfetamine until the point of publication of their Shared Care Policy (SCP), nine (9.5%) patients switched medication, 10 patients initiated additional fast-acting dexamfetamine tablets and two had a second agent added to their therapy (atomoxetine n = 1, methylphenidate n = 1).

Of 25 patients initiated on methylphenidate long acting, 18 (72%) continued this medication at the point of publication of SCP. Of 25 patients initiated on methylphenidate long acting, seven (28%) patients switched medication and two patients were initiated on an additional fast acting methylphenidate.

To successfully stabilise and publish 134 patients on a SCP, 404 brief follow up appointments of 15-minute duration were utilised, which totals 6060 minutes of patient facing time. Of 134 patients, most n = 41 (30.6%) had 2 brief follow-up appointments; 32 (23.9%) had 3 brief follow up appointments and 22 (16.4%) had 4 appointments. Two patients did not attend a follow up appointment, and one patient had 11 brief follow up appointments.

Stimulant medications were typically used as first line treatment however, of these 74% were started on lisdexamfetamine while only 20% were initiated on long acting methylphenidate. Those started on lisdexamfetamine were more likely to continue on this medication to the point shared care agreement than those started on methylphenidate, 28% of whom switched to an alternative, for a variety of reasons. Mean time to reading a shared care agreement was longer for those initiated on methylphenidate long acting compared to lisdexamfetamine.

The data show that for most patients the journey from initiation of a stimulant medication to a shared care agreement was a straightforward one, with the majority having either two or three follow up appointments.

More research is needed to better understand the apparent differences in pathway for those commenced on lisdexamfetamine and long acting methylphenidate.

Interventions to support people with autism are multidimensional, but primarily psychosocial in nature. These interventions include behavioural, educational and support therapies. Some psychotropic medications are used to manage medical and psychiatric comorbidities associated with autism, which interfere with daily social and occupational functioning or limit the implementation of psychosocial interventions. The aim of this study is to describe the trajectories of psychotropic medications in people newly diagnosed with autism according to sex and age.

This is a retrospective cohort study based on medico-administrative data from the Régie de l'assurance santé du Québec. The cohort included all people living in the province of Quebec (Canada) with a first diagnosis of autism (incident cases) recorded during hospitalisation or during a medical visit between January 2012 and December 2016 (index date: first diagnosis). Only individuals covered by the public prescription drug insurance plan one year before and one year after the index date were included. A patient was considered exposed to a drug from the date a prescription was claimed at a community pharmacy and for the time the drug was provided. However, as no information was available on inpatient drug, the drug trajectory represents the outpatient drug trajectory. The five classes of psychotropic drugs considered were: 1) anticonvulsants and mood stabilisers; 2) antipsychotics; 3) antidepressants; 4) anxiolytics/hypnotics; and 5) psychostimulants. Drug trajectories are represented using state sequence analyses.

The study cohort included 3284 people, of which 867 (26.4%) were females and 2417 (73.6%) were males. Overall, 51.6% of the cohort claimed a psychotropic medication in the year preceding diagnosis and 61.1% in the following year, with higher proportions among females and increasing with age. Psychostimulants were the most prescribed medications among people diagnosed at ages ≤12 years, while antipsychotic use increased considerably with age, becoming the most commonly prescribed medication among those diagnosed in adulthood (≥18 years), with use rates reaching as much as 80% among those diagnosed between 36 and 60 years. State sequence analyses demonstrate slight variations in the use of psychotropic medications over time, but significant variations by age category and sex.

Although psychosocial interventions are recognised by clinical practice guidelines as the cornerstone of interventions for people with autism, the use of psychotropic medications is widespread. This highlights a significant gap between the recommendations of these guidelines and what is observed in the real world.

We aim to examine the prescription patterns of local psychiatrists for adolescent patients with depressive disorder, treated on an outpatient basis, as part of an integrated programme for management of mood disorders in adolescent patients (IPMDA) in Singapore.

An longitudinal cohort observational study was carried out at a psychiatry out-patient department in the National University Hospital of Singapore, as part of a specialised programme for the treatment of adolescents, aged 13 to 18, with depressive disorder. The data which were collected included information about age, gender, education, therapy provision and drug prescription included generic name and dosing.

A total of 129 patients were included in the study. 81.7% (n = 105) were females and 18.3% (n = 24) were males. 72 (76.4% female, 23.6% male) patients were started on medications. All patients were initiated on a monotherapy regime of antidepressants.

The most commonly prescribed antidepressant was Fluoxetine (58.3%), followed by Sertraline (18.1%), Fluvoxamine (12.5%), Escitalopram (6.9%), Mirtazapine (2.8%) and Amitriptyline (1.4%).

Our findings revealed that current psychopharmacology practice for depressive disorder in Singapore generally follows the published Singaporean treatment guidelines, which is generally kept up to date with wider international recommendations.

The factor of pricing may affect the lower prescription of certain medications, such as Escitalopram, as it is more expensive than the other prescribed medications in the list.

The prevalence of delirium among confirmed COVID-19 patients is around 12–33%. Delirium in COVID-19 patients is associated with worse functional outcomes; and associated with length of hospital stay, admission to ICU, and ventilator utilization. COVID-19 patients with delirium have a significantly higher risk for mortality than those who did not develop delirium. This study aimed to describe the risk factors, symptomatology, and predictors of mortality of COVID-19 patients presenting with delirium symptoms admitted between January and October 2021 to the Philippine General Hospital, a public tertiary hospital in the Philippines.

Medical records of adult COVID-19 patients admitted to the Philippine General Hospital were analyzed. Descriptive statistics were used to summarize the demographic and clinical history. Univariate and multivariate logistic regression were done to determine the variables that predict mortality.

One in five (20.01%) COVID-19 patients presented with delirium; of the 1,992 medical records reviewed, 400 patients had either presented with symptoms of delirium or were diagnosed with delirium.

Of the 400 patients, 36.5% were not diagnosed with delirium, only 7% were referred to Psychiatry, and 74% expired during admission. Patients referred to Psychiatry had lower mortality odds than those not referred (aOR = 0.069, p = 0.014). Before the COVID-19 pandemic, patients with psychiatric symptoms from organic causes are already less likely to be referred to psychiatrists. Furthermore, studies have shown that delirium is under-recognized among patients with COVID-19. Early referral to a psychiatrist for assessment and management may possibly be protective against mortality.

Those who received midazolam had higher odds of mortality (aOR = 3.112, p = 0.001). Currently, no literature supports the association between midazolam use and mortality among COVID-19 patients with delirium; however, it is known that midazolam use puts patients at increased risk for delirium and mortality.

Patients with decreased sensorium (aOR = 7.438) and decreased psychomotor activity (aOR = 3.857) had higher odds of mortality (p < 0.001). Decreased sensorium and decreased psychomotor activity are typical in patients with hypoactive delirium; hypoactive delirium is a known prognosticator for patient mortality. The only available studies on specific delirium symptomatology show that decreased sensorium and decreased psychomotor activity are common among COVID-19 patients with delirium.

Timely assessment and appropriate management are critical for COVID-19 patients with delirium symptoms, especially those at an increased risk for mortality. Clinicians dealing with COVID-19 patients presenting with delirium must be reoriented to delirium symptomatology, initial interventions, and indications for referral to psychiatrists.